Data Models

Allergy

An allergy or intolerance

• Patient name
• Substance
• Recorded at *
• Practitioner
• Type codeable
• Category codeable
• Criticality codeable
• Status
• Onset age
• Onset at
• Last occurred at
• Note
• Code codeable
• Identifier
       Value *
       Source

Clinical Note

Clinical notes, progress reports, misc. physician-provided info

• Patient name
• Subject
• Recorded at *
• Practitioner
• Contents
• Diagnosis
• Category codeable

Communication

Correspondence between two or more practitioners

• Patient name
• Subject
• Recorded at *
• Recipient
• Sender
• Contents
• Sent at
• Received at
• Note
• Category codeable

Condition

A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.

• Patient name
• Name
• Recorded at *
• Practitioner
• Note
• Severity
• Onset at
• Onset age
• Abatement at
• Abatement age
• Status
• Category codeable
• Code codeable
• Stage
• Identifier
       Value *
       Source

Diagnostic Report

The findings and interpretation of diagnostic tests performed on a patient

• Patient name
• Name *
• Recorded at *
• Practitioner
• Note
• Diagnosis codeable
• Category codeable
• Identifier
       Value *
       Source

Family Member History

A condition applying to a member of the patients family

• Patient name
• Name *
• Recorded at *
• Practitioner
• Gender
• Relationship
• Status
• Birthdate
• Age
• Deceased
• Deceased at
• Category codeable
• Onset age
• Note
• Identifier
       Value *
       Source

Form

A form filled out by or pertaining to a patient, ex intake forms, ER forms. Should have one or more associated files

• Patient name
• Name
• Recorded at *
• Practitioner
• Filled at
• Category codeable
• Note

Goal

A patient or pracitioner established goal

• Patient name
• Target *
• Recorded at *
• Practitioner
• Description
• Status
• Started at
• Due at
• Category codeable
• Diagnosis codeable

Imaging Study

Comprises the results of imaging such as X-RAY, CT, or MRI

• Patient name
• Name * codeable
• Recorded at *
• Practitioner
• Referrer
• Description
• Procedure
• Note
• Started at
• Reason
• Interpreter
• Category codeable

Immunization

Event of a patient being administered a vaccine or a record of an immunization as reported by a patient, a clinician or another party.

• Patient name
• Name * codeable
• Recorded at *
• Practitioner
• Drug name
• Target disease
• Series dose
• Series doses
• Route
• Site
• Administered at
• Description
• Series
• Dosage
       Amount
       Unit
• Note
• Code codeable
• Din
• Reaction
       Reaction at *
       Detail

Medication Dispense

The result of a pharmacy system responding to a medication order or prescription

• Patient name
• Name codeable
• Generic Name codeable
• Recorded at *
• Practitioner
• Prescriber
• Dosage
• Instructions
• Quantity
• Quantity remaining
• Days supply
• Note
• Status
• Manufacturer
• Dispensed at
• Pickup at
• Identifier
       Value *
       Source
• Category codeable
• Code codeable
• Din

Medication Request

An order, request, or prescription for both supply of the medication and the instructions for administration of the medication to a patient.

• Patient name
• Name * codeable
• Generic Name codeable
• Recorded at *
• Practitioner
• Prescriber
• Dosage
• Repeats
• Quantity
• Duration
• Note
• Instructions
• Status
• Manufacturer
• Valid until
• Identifier
       Value *
       Source
• Category codeable
• Code codeable
• Din

Observation

Measurements and simple assertions made about a patient, device or other subject

• Patient name
• Name * codeable
• Recorded at *
• Effective at
• Practitioner
• Result *
• Unit codeable
• Interpretation codeable
• Reference range
       Each item:
           Low
            High
           Type
            Text
           Applies to
  
• Category codeable
• Data absent reason
• Comment

Procedure

An action that is or was performed on or for a patient.

• Patient name
• Name *
• Recorded at *
• Practitioner
• Description
• Note
• Outcome
• Complication
• Reason
• Status
• Performed at
• Performed
• Location
• Category codeable

Resource Group

A collection of sub-resources

• Patient name
• Name *
• Recorded at *
• Practitioner
• Note
• Category codeable

Service Request

A request for a service to be performed

• Patient name
• Recorded at *
• Authored on
• Status
• Requester *
       Name
       Institution       
• Based on
       Reference
       Type
       Display       
• Replaces
       Reference
       Type
       Display       
• Requisition       
• Requested service     
      Service
       Organization          
• Occurrence date time
• Performer *
       Performer name
       Performer type   codeable
       Institution 
• Intent
• Category  codeable
• Priority
• Do not perform
• Code  codeable
• Order detail  codeable
• Encounter
       Reference
       Type
       Display
• As needed
       asNeededBoolean 
       asNeededCodeableConcept  codeable
• Reason code
       Text
       Coding
            Each item:
               System*
               Code*
  
• Supporting info
       Reference
       Type
       Display
  
• Body site  codeable
• Note
  
• Patient instruction
  
• Summary
  

* required field

Fields marked "codeable" have a special format that accepts both text values (ex. "White Blood Cell Count") and/or codes from various systems. For codes, you may specify two values: the code used (ex. 26464-8) and the code system (ex. LOINC).